As the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is implemented in January with new models for quality-based reimbursement payments, rheumatologists must seize control of how they will be paid now—and in the future. This message was stressed by speakers during Holy MACRA! How to Survive and Thrive in the Era of MACRA, MIPS, and APMs, an informational session held on Nov. 13 at the 2016 ACR/ARHP Annual Meeting in Washington, D.C.
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A Step in the Right Direction
MACRA repackages some existing, incentive-based quality payment programs, such as Meaningful Use, said William F. Harvey, MD, MSc, FACR, clinical director of the Arthritis Treatment Center at Tufts University Medical Center in Boston and a member of the ACR Board of Directors.
“While not ideal, this is certainly a step in the right direction,” said Dr. Harvey. The ACR provides education to members about MACRA reporting options, and the Rheumatology Informatics System for Effectiveness (RISE) [Registry], a free, qualified clinical data registry, allows users to immediately earn points for
improved payment scores, he said.
MIPS Now, APMs Later
The Centers for Medicare and Medicaid Services (CMS) offers physicians the choice of two quality reporting pathways: participation in 1) the Merit-Based Incentive Payment Systems (MIPS) or 2) an Advanced Alternative Payment Method (APM). Most rheumatology practices will likely choose the fee-for-service MIPS track now, but CMS will continue to steer providers toward APMs in the future, said Dr. Harvey.
“Although the payment adjustments in the MIPS pathway start in 2019, the performance period for which you will collect and submit data that determine your 2019 payment adjustment starts on Jan. 1, 2017. So you need to be prepared. It’s urgent that you start thinking about this now, whether you’re an employed physician or not. This will affect you,” he said.
MACRA is budget neutral. Reimbursement money will be divided among participants on the basis of their scoring percentile, and a threshold score will divide providers who receive negative payment adjustments and those who receive positive adjustments, he said.
MIPS: Report & Score
MIPS gives providers a score of 0 to 100 points based on their reported activities in Quality, Resource Use, Clinical Practice Improvement Activities, and Advancing Care Information, which replaces Meaningful Use. The positive payment threshold for the 2017 performance period is only three points out of 100, Dr. Harvey said. He emphasized that in response to requests from the ACR and others for more flexibility early in the program, rheumatologists can submit any single data item to avoid a negative adjustment for the first year. Providers who score 70 or more points will qualify for a pool of high-performance threshold money.
“If you’re already doing Meaningful Use, or doing some kind of practice awareness, care coordination or patient engagement activities in your practice, you may be able to achieve 70 in that first year and gain access to that money,” he said.
Quality measures will make up 60% of the score the first year and include screening for tuberculosis within six months of starting a biologic; documenting functional status, disease activity and prognosis in RA patients; and glucocorticoid management in RA patients, among other measures.
“These are things you probably do all the time. Now, you just have to choose measures, document and report them,” said Dr. Harvey.
Providers may choose from more than 90 practice improvement activities to report, such as patient engagement activities or care coordination among a patient’s various healthcare providers.
“We’ve never been able to get paid for care coordination. But now, if you do this and do it well, you can get paid for it. Extended office hours are another measure. That’s a patient engagement activity. Think about things you already do in your practice,” he said.
In MACRA’s first performance year, resource use, or cost, is set at zero, which benefits rheumatologists because they often prescribe expensive drugs, said Dr. Harvey.
“The ACR will prioritize our advocacy efforts to make sure they appropriately take drug costs into account in the future. We want to ensure that we influence this in a way that’s beneficial to rheumatologists,” he said.
Use RISE for Points
Rheumatologists who use RISE automatically earn practice improvement points, said Dr. Harvey. RISE submits data directly to the CMS, with no need for additional data entry.
In the Advancing Care Information category, physicians will report on five different measures:
- Doing an EHR security risk analysis;
- Providing patient access to their EHR records;
- Sending a summary of care report from one electronic record to another; and
- Acceptance of that report.
Those who do Meaningful Use will score well in this category, said Dr. Harvey.
To predict how well your practice will fare through MIPS, examine your current adjustments through Meaningful Use, and look at your Quality Research Utilization Reports to see how your practice compares with your peers’ scores, he said.
“If you are an employed physician or part of a large group that’s already doing these activities, you are at an advantage already,” he said.
In MACRA, Congress encouraged physicians to participate in APMs by exempting them from MIPS, and giving them 5% lump-sum bonuses for five years and higher annual updates, said Harold D. Miller, president and CEO of the Center for Healthcare Quality and Payment Reform.
To create an APM that works well for rheumatologists and their patients, the ACR has engaged Mr. Miller as a consultant. APMs are needed because existing reimbursement models don’t pay physicians for the types of services that provide better outcomes and lower-cost care, said Mr. Miller.
“If you answer an emergency phone call that could keep a patient out of the hospital, there’s no payment for that,” he said. “There’s no payment for the time a physician spends on the phone trying to communicate with other providers to figure out what’s wrong with a patient. There’s no payment for hiring a nurse to provide patient education that will help patients manage their disease more effectively.”
Although many APMs to date have been designed as “shared-savings models,” they provide only temporary bonuses to physicians who can lower spending and no up-front resources to improve care, said Mr. Miller. This model doesn’t benefit providers who are currently efficient in how many procedures or tests they order, and it doesn’t provide sustainable support for new approaches to care delivery.
“Rather than forcing physicians to change patient care so it aligns with payment systems created by payers, physicians need to decide how to redesign care to get better results and then ask payers to pay them that way,” he said.
DIY Physician-Focused Payment Models
Rheumatology could potentially create its own physician-focused payment model that supports care for chronically ill patients who benefit from interventions that prevent long-term damage and costly complications, Mr. Miller said. One model is SonarMD, a payment and care delivery system created by an Illinois gastroenterologist who based the system on data he obtained from a commercial payer about the complications his patients were experiencing and the costs of treating them. This payment model reimburses practices for interventions specifically designed to improve care for patients with inflammatory bowel disease, such as using nurse care managers to guide patients’ self-management.
“A good APM provides flexibility and resources physicians [can use] to deliver better services. But physicians can’t just say ‘pay us more and trust us.’ An APM requires physicians to take accountability for achieving the improvements in cost and quality that better care can deliver,” Mr. Miller said.
To that end, APMs should be designed to focus accountability on the things that physicians can control, without putting physicians at risk for aspects of cost and quality they can’t control, Mr. Miller said. For example, rheumatologists can’t prevent autoimmune diseases, but they can treat them in less costly ways that achieve better outcomes. Rheumatologists excel at diagnosing complex illnesses so patients can get appropriate care sooner, he said. A good payment model will support their ability to work with primary care physicians and others to identify the most appropriate rheumatology-specific interventions.
“This could include using lower-cost medications, avoiding routine MRIs or avoiding joint surgery for patients by managing their condition better. These are all opportunities to have a significant reduction in cost,” said Mr. Miller.
Primary care physicians (PCPs) may function, and be paid, as the accountable medical home for some arthritis patients, but a medical neighborhood of specialists, including rheumatologists, may need to work with the PCP to properly diagnose and treat these patients. For patients with serious conditions, rheumatologists may need to serve as the medical home, said Mr. Miller.
Rheumatologists can help develop payment models designed to work for their subspecialty, he said. In closing Dr. Harvey noted that the ACR is doing exactly this type of work to explore creation of a rheumatology-specific APM in order to help position rheumatologists for success under MACRA.
Missed This Important Session?
If you were unable to attend the session, Holy MACRA! How to Survive and Thrive in the New Era of MACRA, MIPS, and APMs, during the 2016 ACR/ARHP Annual Meeting, catch it now on SessionSelect.
Susan Bernstein is a freelance medical journalist based in Atlanta.
Note: Review the ACR’s comments to CMS on the final rule.